Sirago - Ultimate Gap Cover
Sirago Ultimate Gap Cover is comprehensive gap cover, for peace of mind.
It includes generous in-hospital gap cover with an additional 500% above the medical scheme rate, co-payment cover, penalty fee and extended cancer benefits, out-patient surgical procedures, appliance benefit, sub-limit enhancer cover, out-patient specialist and primary care cover, emergency room treatment, step-down facilities, preventative care and trauma counselling, subject to available limits.
Gap Cover Benefits
| Co-payment benefit |
Subject to R191 000 per insured person per annum.CO-PAYMENTS subject to OAL. PENALTY FEES will be covered up to R14 000 per incident with a maximum of 3 (three) claims per annum for the voluntary use of a Hospital or Day Clinic outside your medical scheme's Designated Network. |
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| Dental benefit |
Specialized Dentistry is covered in hospital only |
| Diagnosis benefit |
Once-off payment of R27 500 when you are diagnosed with cancer for the first time. Only 1 claim per insured person per annum as defined. |
| Emergency/casualty benefit |
Provides cover when you visit the emergency room for accident and trauma / child emergency illness benefit for children 8 years and under. R2 000 Emergency illness benefit for persons 9+ years, subject to the sublimit. We will cover a GP if there no emergency hospital is available within a 30Km radius. Benefit is limited to R12 000 per policy per annum. Subject to R191 000 (OAL) per beneficiary per annum. |
| Full time students over 21 |
Covered up to the age of 27 as long as they are full-time students (including if they are on their own option) – they do not have to be unmarried |
| Gap cover limits |
An Overall Annual Limit (OAL) of R191,000 per beneficiary per annum, for in- and out-of-Hospital surgical |
| Gap cover percentage benefit |
An additional 500% of what your medical scheme paid and with no limit on the number of times you may claim per year. This includes cover for doctor's, specialists, basic radiology, pathology, physiotherapy as well as PMB conditions. Robotic surgery limited to R35 000 per annum, R19 000 per claim. BMI 0018 & 0019 and subject to OAL. |
| Lives Covered |
Main medical scheme member; All family members registered as medical scheme dependants OR no more than 2 Adults and 3 Child dependants on different medical schemes |
| Maximum entry age |
There is no maximum entry age applicable |
| Oncology benefit |
The oncology co-payment benefit is applicable to the co-payment imposed by the medical aid once the oncology limit is reached. Subject to R191 000 per insured person per annum. In the event of the Medical Scheme approving reconstructive surgery on the affected breast, we will cover the Gap portion of 500% of the claim. In addition to this, Sirago will make available R27 500 (Stated Benefit) for the reconstruction of the non-affected breast, with supporting documentation. |
| Oncology supplementary benefit |
Cancer Boost Benefit is subject to R191 000 per insured person per year. This can be claimed once your Rand limit on your Medical Scheme Oncology benefit has been reached and you need further treatment. In the event of the Medical Scheme approving reconstructive surgery on the affected breast, we will cover the Gap portion of 500% of the claim. In addition to this, Sirago will make available R27 500 (Stated Benefit) for the reconstruction of the non-affected breast, with supporting documentation. |
| PMB cover |
Prescribed Minimum Benefits are covered for the use of Non-DSP facility for PMB treatment *No cover for emergency or involuntary PMB treatment |
| Sub-limit benefit |
Sub-limit of R26 500 per claim subj to OAL. The Sublimit Enhancer benefits are limited to MRI / CT scans, Intraocular lenses, cochlear implants and Internal Prosthesis. Subject to R191 000 per insured person per annum. |
| Trauma counselling |
R8 000 sub-limit per policy per annum. A stated benefit of R950 per claim You will be covered within the first 6 months after a traumatic event with a registered medical professional. This benefit covers you but not limited to; Dread Disease, Hijacking and or Violent Crimes at the discretion of the Insurer on the provision of supporting documentation Subject to R191 000 per insured person per annum |
Gap Cover Contributions
| Contributions |
R498 for individuals (0 - 64) R566 for families (0 - 64) R714 for individuals (65+) R821 for families (65+) |
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